METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students' Faculty

MODULE 2. PRINCIPLES OF INTERNAL MEDICINE (cardiology, rheumatology, nephrology, common questions of internal medicine)

Content module 1. Principles of diagnosis, management and prevention of main cardiovascular diseases

LESSON № 1 (PRACTICAL - 6 hours)

 

Theme 1: Main symptoms and syndromes in cardiology. Essential arterial hypertension    

 

Aim: to develop skills and to acquire experience relevant to management of patients with cardiovascular diseases, in particular those with essential arterial hypertension.

Professional Motivation: cardiovascular disease remains the major cause of morbidity and mortality throughout the developed world and it is also rapidly increasing in the developing world. As one of the world’s most widespread diseases, hypertension not only poses its own specific threats and challenges but it also contributes to heightened risk of various cardiovascular diseases and renal failure. Fortunately, increased scientific inquiry is contributing to a better understanding of hypertension, its contribution to numerous disease process, and more treatment options for patients with chronic elevated blood pressure.

 

Methodology of Practical Class

Introduction by the teacher, control the initial level of knowledge – 09.00-09.30

Individual students' work with patients - 09.30-12.00

Break – 12.00-12.30

Seminar (discussion of theoretical questions, practical work with patients) - 12.30-14.00

Break – 14.00-14.15

Individual work 1415-1500 (students who didn`t pass the tests in Moodle system, complete the individual work).

 

 

Algorithm of students’ communication with patients with pathology in subject (communication skills):

During examination of the patient students have to use such communicative algorithm:

Complaints and anamnesis taking in patients

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Take complaints and anamnesis in a patient.

5. Explain to the patient results of his/her lab tests correctly and accessibly.

6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.

7. Conversation accomplishment.

Objective examination:

Physical methods of examination of patients with internal diseases

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a patient, what examinations will be carried out and get his/her informed consent.

5. Find a contact with the patient and make an attempt to gain his/her trust.

6. Inform about the possibility of appearing of unpleasant feelings during the examination.

7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).

8. Examination (demonstration of clinical skill).

9. Explain to the patient results of his/her lab tests correctly and accessibly.

10. Conversation accomplishment.

Estimation of laboratory and instrumental investigations

Informing about the results of examination of patients with internal diseases

1. Friendly facial expression and smile.

2. Gentle tone of speech.

3. Greeting and introducing.

4. Explain to a patient results of his/her lab tests correctly and clearly.

5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).

Planning and prognosis the results of the conservative treatment

Friendly facial expression and smile.

1. Gentle tone of speech.

2. Greeting and introducing.

3. Correct and clear explanation of necessary treatment directions.

4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.

5. Conversation accomplishment.

 

Work 1. Work at the patient’s ward.  The student collects the complaints, anamnesis of disease and life, perform objective examination of the patient, identify the main syndrome, formulate preliminary diagnosis and prescribe plan of investigations.

Work 2. The student estimates results of laboratory and instrumental investigations, makes a differential diagnosis and formulates the clinical diagnosis, based on the diagnostic criteria of the disease.

Work 3. The student prescribes appropriate treatment and defines individual management program for patient.

 

Individual Students Program

·                  Under the tutor’s supervision students should be able to elicit the patient’s chief complaint, history of present illness, past medical history, social, family, occupational histories and complete a review of systems.

·                  Perform a physical examination in a logical, organized and thorough manner.

·                  Demonstrate the ability to construct an assessment and plan for an individual patient organized by problem, discussing the likely diagnosis and plan of treatment.

·                  Demonstrate the ability to record the history and physical in a legible and logical manner.

·                  Demonstrate the ability to write daily progress notes on the ward and appropriate outpatient progress notes.

·                  Orally present a new patient's case in a focused manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment.

·                  Orally present a followup patient's case, focusing on current problems, physical findings, and diagnostic and treatment plans.

·                  Diagnostic Decision Making

·                  Formulate a differential diagnosis based on the findings from the history and physical examination.

·                  Use the differential diagnosis to help guide diagnostic test ordering and its sequence.

·                  Participate in selecting the diagnostic studies with the greatest likelihood of useful results.

·                  Recognize that tests are limited and the impact of false positives/false negatives on information.

·                  Test Interpretation

·                  Describe the range of normal variation in the results of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram, chest X-ray, urinalysis, pulmonary function tests, and body fluid cell counts.

·                  Describe the results of the above tests in terms of the related pathophysiology.

·                  Understand test sensitivity, test specificity, pre-test probability and predictive value.

·                  Understand the importance of personally reviewing X-ray films, blood smears, etc., to assess the accuracy and importance of the results.

·                  Therapeutic Decision Making

·                  Describe factors that frequently alter the effects of medications, including drug interactions and compliance problems.

·                  Formulate an initial therapeutic plan.

·                  Access and utilize, when appropriate, information resources to help develop an appropriate and timely therapeutic plan.

·                  Write prescriptions accurately.

·                  Monitor response to therapy.

 

Seminar discussion of theoretical issues

1. Etiology and pathophysiology issues.

2. Classification

3. Main clinical findings

4. Main laboratory and instrumental findings

5. Management strategies: principles of choice of the right strategy

6. Drug therapy: indications and contraindications

 

 

Test evaluation and situational tasks.

Multiple Choice Questions

Choose the correct answer/statement

1.                   A 42-year-old male comes in for a routine physical examination. He is noted to have a BMI of 30, impaired fasting glucose, and a BP of 135/85 mmHg. What is the best treatment plan for this individual?

A.               Aggressive lifestyle modification*

B.               Institute thiazide diuretic regimen

C.               No treatment at this time

D.               Initiate an ACE-inhibitor

E.                Initiate a beta-blocker

2.                   A 62-year-old man with isolated essential hypertension, currently taking hydrochlorothiazide 25 mg PO daily, comes to you for his first clinic visit. He notes that his BP at home is always less than 140/80 mmHg, but in clinic it is always at least 155/95 mmHg. What is the next step?

A.               Increase dose of thiazide

B.               Addition of second antihypertensive medication

C.               Do nothing as he has white coat hypertension*

D.               Evaluate for secondary causes of hypertension

E.                Start metoprolol

3.                   A 34-year-old male with isolated essential hypertension presents to clinic and is found to have a BP of 180/100 mmHg after failure of behavioral modifications. What is the most appropriate next step?

A.               Start hydrochlorothiazide

B.               Start hydrochlorothiazide and lisinopril*

C.               Repeat BP in 4 weeks

D.               Start amlodipine

E.                Start doxazozin

 

4.                   A 56-year-old male on hydralazine, hydrochlorothiazide, lisinopril, and metoprolol begins to develop a malar rash and arthralgias. Which of the above antihypertensive agents is known to cause drug-induced lupus?

A.               Hydrochlorothiazide

B.               Lisinopril

C.               Hydralazine*

D.               Metoprolol

E.                None of the above

 

5. Which lifestyle change has been shown to produce the biggest reduction in systolic blood pressure?

A. 10-kg weight loss*

B. Dietary sodium reduction

C. Moderation of alcohol consumption

D. Change to a vegetarian diet

E. Magnesium supplement

 

6. All of the following findings are suggestive of LVH except:

a.            (S in V1 + R in V5 or V6) > 35 mm

b.            R in aVL > 11 mm

c.             R in aVF > 20 mm

d.            (R in I + S in III) > 25 mm

e.             R in aVR > 8 mm*

 

7. All of the following findings are suggestive of RVH except:

a.            R in V1=7 mm (15 mm with RBBB)

b.            (R in V1 + S in V5 or V6) > 10 mm

c.             R < S in V6

d.            R or R’ in V1

e.             S in V3 + R in aVL > 28 mm (20 mm for women)*

 

 

8. Which of the following pairs of medical conditions and antihypertensive medications would be incorrect to use in a patient with essential hypertension?

A.               Beta-blocker and a history of myocardial infarction

B.               Alpha-blocker and prostatic hypertrophy

C.               Thiazide diuretic and gout*

D.               Amlodipine and heart failure

E.                ACE-inhibitor and diabetes mellitus

 

9. A 34-year-old female with hypertension is considering becoming pregnant. Which of the following medications would be absolutely CONTRAINDICATED to control her BP during pregnancy?

A.               Methyldopa

B.               Metoprolol

C.               Labetalol

D.               Captopril*

E.                Nifidipine

 

10. Which of the following antihypertensive agents is INCORRECTLY matched with the indication for therapy?

A.               ACE inhibitor – diabetic nephropathy

B.               Beta-blocker – coronary artery disease

C.               Calcium channel blocker – angina pectoris

D.               Hydrochlorthiazide – diabetes mellitus*

E.                Loop diuretic – heart failure

 

Real-life situations to be solved:

1. A 49-year-old female presents to you for an initial visit to establish health care. She has no past medical history and denies a family history of diabetes mellitus, early cardiovascular disease, or renal disease. Her BP on presentation is 185/110 mmHg. She denies headache or visual complaints. She has no chest pain, shortness of breath, or change in urine color. Her physical examination is normal with the exception of an S4 gallop heard at the 4th intercostal space just to the left of the sternum. An ECG is significant for LVH and LAD. There are no signs of cardiac ischemia. Urinalysis shows no red blood cells or proteinuria. What is your recommendation for therapy for this patient?

A. Initiate therapy with hydrochlorothiazide in combination with a beta-blocker

B. Initiate therapy with hydrochlorothiazide alone

C. Initiate therapy with an ACE inhibitor alone

D. Advise the patient to go to the nearest emergency department for further treatment for a hypertensive emergency

E. Advise the patient on lifestyle modifications and plan a return visit in 3 weeks

2. At a routine examination, an asymptomatic 46-year-old man is found to have a BP of 150/110 mmHg, but no other abnormalities are present. What do you do next?

A. Reassure the patient and repeat the physical examination in 12 months

B. Initiate antihypertensive therapy

C. Obtain repeated BP recordings in your office and/or the patient’s home or work site

D. Hospitalize patient for renal arteriography

E. Order a 24-h ambulatory BP monitoring

 

Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions (the instructor has tests & situational tasks)

 

Students should know:

1. General cardiovascular anatomy and physiology.

2. Anatomy and hemodynamics in normal and hypertensive subjects.

2. Relevant terminology, definitions and classifications.

3. Chief complaints of cardiac patients.

4. Evaluation of basic signs and symptoms

5. Specific signs and symptoms.

6. Methods of physical examination of cardiovascular patients.

7. Methods of laboratory evaluation of cardiovascular patients.

8. Methods of instrumental evaluation of cardiovascular patients.

9. Principles of management.

 

Students should be able to:

1. Perform a clinical exam of cardiovascular patients.

2. Reveal main clinical syndromes.

3. Draft a plan of laboratory and instrumental evaluation of cardiovascular patients.

4. Assess the results of laboratory and instrumental evaluation.

5. Diagnose the condition and formulate the diagnosis according to current classification.

6. Perform differential diagnosis.

7. Prescribe the appropriate therapy.

 

Correct answers of test evaluations and situational tasks:

1. Real-life situations. The correct answer is A. (see Harrison’s PRINCIPLES OF INTERNAL MEDICINE, 16th ed., Chap. 230; JAMA 2003; 289:2560-2572). The most recent recommendation for the treatment of hypertension is for the initiation of combination therapy as first-line treatment if BP is higher than 160/100 mmHg. A thiazide diuretic should be a part of all combination regimens and can be combined with an ACE inhibitor, calcium channel blocker, angiotensin receptor blocker, or beta-blocker. The patient has no signs of hypertensive emergency and has no evidence of end target organ damage on physical and laboratory examination. Thus, the patient does not need i.v. administration of antihypertensive medications and can be safely managed as an outpatient on oral medications with close follow-up. Lifestyle modifications have at least been shown to lower systolic BP by 10 to 20 mmHg and would not alone be sufficient for traetment of this degree of hypertension.

2. E. Order a 24-h ambulatory BP monitoring

 

References.

A - Basic:

1. Davidson’s Principles and practice of medicine (21st revised ed.) / by Colledge N.R., Walker B.R., and Ralston S.H., eds. – Churchill Livingstone, 2010. – 1376 p.

2. Harrison’s principles of internal medicine (18th edition) / by Longo D.L., Kasper D.L., Jameson J.L. et al. (eds.). – McGraw-Hill Professional, 2012. – 4012 p.

3.  The Merck Manual of Diagnosis and Therapy (nineteenth Edition)/ Robert Berkow, Andrew J. Fletcher and others. – published by Merck Research Laboratories, 2011.

4.  Web -sites:

a)  www.tdmu.edu.ua:Main symptoms and syndromes in cardiology.

b)  http://emedicine.medscape.com/

c) http://meded.ucsd.edu/clinicalmed/introduction.htm

 

B - Additional:

1. Braunwald’s Heart Disease: a textbook of cardiovascular medicine (9th ed.) / by Bonow R.O., Mann D.L., and Zipes D.P., and Libby P. eds. – Saunders, 2012. – 2048 p.

2. Braunwald’s Heart Disease: review and assessment (9th ed.) / Lilly L.S., editor. – Saunders, 2012. – 320 p.

3. Cardiology Intensive Board Review. Question Book (2nd ed.) / by Cho L., Griffin B.P., Topol E.J., eds. – Lippincott Williams & Wilkins, 2009. – 385 p.

4. Cleveland Clinic Cardiology Board Review / Griffin B.P., Kapadia S.R., Rimmerman C.M., eds. – Lippincott Williams & Wilkins, 2012. – 952 p.

5. Hurst’s the Heart (13th ed.) / by Fuster V., Walsh R.A., Harrington R., eds. – McGraw-Hill, 2010. – 2500 p.

5. Oxford Handbook of Cardiology (2nd ed.) / by Ramrakha P., Hill J., eds. – Oxford University Press, 2012. – 851 p.

 

 

Methodical instruction has been worked out by:  assos. prof. R.R. Komorovsky, MD

Methodical instruction was discussed and adopted at the Department sitting 15.06.2009, Minute № 2

Methodical instruction was adopted and reviewed at the Department sitting 29.06.2010, Minute № 19

Methodical instruction was adopted and reviewed at the Department sitting 16.06.2011, Minute № 13

Methodical instruction was adopted and reviewed at the Department sitting 12.06.2012, Minute № 12

Methodical instruction was adopted and reviewed at the Department sitting 25.06.2013, Minute № 17